About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.

Source · Domestic Homicide Review

Wolverhampton review

CSP: Wolverhampton Published: August 2023 Year of death: 2019 Extracted: 8 recs

Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.

View full report (PDF) ↗ Source: Home Office DHR Library

Summary

The report identifies systemic missed opportunities by agencies to identify and address domestic abuse, self-harm, and substance misuse. There was a lack of a 'Think Family' approach, inadequate multi-agency coordination, and insufficient information sharing regarding the victim's complex vulnerabilities, particularly for an older adult not meeting Care Act thresholds.

Extracted recommendations

8 recommendations pulled from the report

#	Recommendation	Addressed to
1	The DHR recommends that the Safer Wolverhampton Partnership seek assurances from the Wolverhampton Clinical Commissioning Group (CCG), the Black Country Healthcare Foundation Trust (BCHFT) and the Royal Wolverhampton Trust (RWT) that appropriate and safe questioning of patients around risk of domestic abuse (in-line with current NICE guidance) is now taking place and that a record confirming questioning has occurred is made on patient notes, regardless of outcomes.	Safer Wolverhampton Partnership \| Wolverhampton Clinical Commissioning Group \| Black Country Healthcare Foundation Trust \| Royal Wolverhampton Trust
2	The DHR recommends that the CCG, BCHFT, Adult Social Care and the RWT review policy and procedures and guidance and training to ensure that they can demonstrate that ‘Think Family’ principles inform practice and that professionals obtain where appropriate a detailed family history and explore a patient’s social situation.	Wolverhampton Clinical Commissioning Group \| Black Country Healthcare Foundation Trust \| Adult Social Care \| Royal Wolverhampton Trust
3	The DHR recommends that the Safer Wolverhampton Partnership should seek an account from Wolverhampton Safeguarding Together and Public Health of their Review of service provision and pathways (both statutory, voluntary and third sector), which is aimed at improving early identification of need and preventing harm to vulnerable adults who may otherwise develop care and support needs and be at risk of abuse or neglect	Safer Wolverhampton Partnership \| Wolverhampton Safeguarding Together \| Public Health
4	The Safer Wolverhampton Partnership should seek assurances from the CCG and WST that the protocols for multi-disciplinary and concerns meetings would allow a professional to convene a meeting where an adult presented with similar needs to those of the victim in this case.	Safer Wolverhampton Partnership \| Wolverhampton Clinical Commissioning Group \| Wolverhampton Safeguarding Together
5	The DHR recommends that the Wolverhampton MASH and Adult Social Care should identify how, following a safeguarding referral, an accurate understanding of any unresolved risks can best be shared and communicated to all agencies involved with that adult (and made available to those agencies that go on to work with an adult). This summary should be recorded and be easily accessible to relevant agencies, to reduce the risk of incomplete information sharing.	Wolverhampton MASH \| Adult Social Care
6	The DHR recommends that the CCG, RWT and BCHFT should consider refreshing guidance to their professionals concerning safety planning after a self-harm incident, informed by NICE Self Harm Clinical Guidance 133	Wolverhampton Clinical Commissioning Group \| Royal Wolverhampton Trust \| Black Country Healthcare Foundation Trust
7	The DHR would recommend commissioners of mental health services in Wolverhampton should explore the feasibility of funding suicide prevention services for adults of any age who may self-harm or report suicidal ideation	Commissioners of mental health services in Wolverhampton
8	The DHR would propose to Wolverhampton Safeguarding Together that the Learning & Improvement subgroup consider how best learning from this DHR, and particularly learning related to elder abuse and interfamilial violence, be communicated broadly to frontline professionals	Wolverhampton Safeguarding Together
Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗